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Dogma in EMS: Backboards Casey Fox, DO Adapted from: The Evidence Against Backboards(1) by Bryan Bledsoe, DO

How often have you seen the healthy, young, low speed MVC patient who was ambulatory at the scene brought in by EMS on a rigid backboard and in full cervical spine (c-spine) precautions? It makes for a great pimping session with the medical student about the NEXUS criteria but often we immediately clear the patient’s c-spine clinically and immediately move them off of the backboard, often without any further imaging. Have you found yourself wondering why she was on a backboard in the first place? I have many times.

With the introduction of the 1984 DOT EMT curriculum(2), which intended to “dumb down” the curriculum taught to EMTs at the time, the indications for placing a patient on a rigid backboard became so broad it might as well have included the presence of a backboard as an indication to use one. The origins of using a backboard can possibly be traced to trauma surgeon J.D. “Deke” Farrington’s recommendation back in 1968(3). Reviewing the recent evidence shows no proof that spinal immobilization improves patient outcomes. On the contrary, many studies have shown the way we assume backboards function actually doesn’t occur. Cervical collars have not been shown to actually restrict cervical motion compared to no collar(4), spinal immobilization methods are ineffective during simulated vehicle motion(5), and another study concluded that obtaining “full cervical immobilization is a myth”(6). An observational study comparing blunt spinal cord injury patients in New Mexico and Kuala Lumpur (Malaysia) showed less neurologic disability in the Malaysian patients. All patients in New Mexico were immobilized, none of the Malaysian patients were ever immobilized(7).

Not only is there a lack of evidence showing a benefit of full spinal immobilization, placing a patient on a backboard can cause adverse effects. Pain is a common occurrence with spinal immobilization (8,9), managing an airway becomes more difficult by limiting mouth opening(10), backboards restrict respirations(11), and some have hypothesized that immobilization of the spine (particularly the c-spine) contribute to airway obstruction to the point that “immobilization may increase mortality and morbidity…”(12). Obviously, the clinical judgment of an experienced clinician should never be ignored. However, spinal injuries are uncommon. In a study of over 34,000 patients with blunt trauma, only 2.4% had c-spine injuries, the majority were stable and almost 30% of the total injuries were considered insignificant(13). Another study with more than 57,000 assaulted trauma patients showed that c-spine fractures from blunt trauma occurred at a rate of 0.41%, in gunshot wounds the number was 1.35%, and it was 0.11% for stab wounds(14). Furthermore, spinal cord injuries in penetrating trauma almost always exhibit obvious neurologic deficits(15). It has also been demonstrated that prehospital spinal immobilization is correlated with a higher mortality in penetrating trauma patients and the authors recommended against its routine use in this population(16,17). In light of these studies the Prehospital Trauma Life Support (PHTLS) Executive Committee made new recommendations(18): · There are no data to support routine spine immobilization in patients with penetrating trauma to the neck or torso. · There are no data to support routine spinal immobilization in patients with isolated penetrating trauma to the cranium. · Spine immobilization should never be done at the expense of accurate physical examination or identification and correction of life-threatening condition in patients with penetrating trauma. · Spinal immobilization may be peformed after penetrating injury when a focal neurologic deficit is noted on the examination, although there is little evidence of benefit even in these cases.

Is it time to start deconstructing the dogma of full spinal immobilization in the prehospital setting yet? Patients that receive this treatment are at an increased risk of aspiration and pain, they require more intense nursing care until removed from the backboard, are probably more likely to receive advanced imaging compared to those that did not arrive in spinal immobilization and thus increase Emergency Department resource utilization. Even after c-spine injuries are often identified those patients are then placed on soft beds with continuation of their cervical collars.

Many EMS personnel have (anecdotally) expressed similar frustration with the current culture of using backboards and performing too much immobilization. Unfortunately they are bound by their protocols, which are written by Emergency Medicine physicians, who ascribe to practicing evidence-based medicine.

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